Tinnitus: Causes and Solutions for Nighttime Symptoms - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

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Dear Miss Huihui, please come to the clinic for a detailed examination to determine the underlying issue.
My clinic hours are Monday, Wednesday, Thursday, and Friday mornings.
Here is a reference document for you.
┌─── 　■ Yeh Da-Wei ENT Clinic Medical Education ■　 ───
2000/03/20
The leading dizziness specialist in the Zhunan-Miaoli area, a pioneer in online medicine in Taiwan.
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This article will be organized later on the 【 Yeh Da-Wei ENT Clinic website / Health Education 】.
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【 "Local Surrounding Central" – Correct Concepts for Treating Tinnitus 】
Mr.
Chang Jun-Hong from the Democratic Progressive Party wrote a small book years ago titled "The Road to Governance – The Theory and Practice of 'Local Surrounding Central'." In it, he discussed how the opposition party could first gain local governance through elections of county and city mayors in Taiwan, and then push towards the central government and even the presidential election.
This strategy of surrounding the central government from the local level can also be applied to the diagnosis and treatment of the bothersome condition known as tinnitus.
Tinnitus is a very subjective experience.
After a basic local examination by an ENT specialist, which rules out earwax or otitis media, doctors often arrange for hearing tests.
If hearing loss is observed and is of a neurological nature, the doctor can only prescribe oral medications to prevent further deterioration of hearing, but there are no specific remedies for tinnitus treatment.
If the hearing test shows normal results, it is often considered purely a psychological issue.
The concept of "Local Surrounding Central" suggests that tinnitus is rarely a singular event; patients often have other underlying conditions, and tinnitus may just be one of the clinical manifestations of these diseases.
If treatment can be approached from the perspective of other clinical symptoms, and if these objective symptoms (like "local") improve, leading to the subjective tinnitus (like "central") disappearing, we can consider the treatment successful.
With the prosperity of the economy, there has been a corresponding increase in patients with hypertension and hyperlipidemia.
Changes in entertainment among younger populations, such as KTV, concerts, and portable music players, are also major causes of noise-induced tinnitus.
Additionally, the intense competition in industrial society has led to vascular spasms in the cochlea, and the aging population has resulted in more cases of age-related vascular tinnitus.
These are all factors that an ENT specialist must consider when treating tinnitus.
Below is an introduction to diseases related to tinnitus.
● Classification of Tinnitus
"Tinnitus is a gradual onset of deafness," and "if tinnitus persists, it will lead to deafness." These ancient phrases highlight the serious possibility that tinnitus can lead to significant hearing loss.
The English term for tinnitus comes from the Latin word meaning "to ring." Scholars generally classify tinnitus based on its causes as follows:
○ Cochlear Tinnitus
Cochlear tinnitus, as the name suggests, is caused by lesions in the inner ear.
The most well-known conditions include Meniere's disease and the increasingly common sudden sensorineural hearing loss.
I have discussed this in my article "A Talk on Dizziness," and I will reiterate it here.
1.
Meniere's Disease
When the general public thinks of dizziness, they often think of "Meniere's," and even general practitioners may diagnose it as such.
In reality, there are not as many cases of Meniere's disease as one might think; many patients who complain of dizziness are often overdiagnosed by physicians.
Therefore, if the number of Meniere's cases is disproportionately high among patients in a neurotology clinic, the physician's competence may be called into question.
Simply put, if a patient experiences dizziness, tinnitus, and hearing loss, the doctor will consider this disease.
The renowned Japanese physician Ichiro Kitabatake even described it as a "7 points disease" due to the following characteristics:
1) Severe dizziness: It feels as if the world is spinning and can last for several hours, with the first episode being the most intense.
2) Spontaneous dizziness: It occurs without any apparent trigger and can strike suddenly.
3) Recurrent dizziness: Patients with Meniere's disease often experience repeated episodes, rarely just one occurrence.
4) Reversible dizziness: There are periods of complete normalcy between episodes; it does not persist for days.
5) Dizziness accompanied by cochlear nerve symptoms: Patients often experience fluctuating hearing loss during acute episodes, with severe tinnitus and sometimes perceive sounds at different frequencies.
6) Hearing loss is often more pronounced at low frequencies.
7) There is a "reverberation phenomenon," where patients often complain of discomfort in noisy environments, such as markets or train stations.
To date, no laboratory test can definitively diagnose Meniere's disease, making a detailed medical history and basic physical examination very important.
Patients often experience unforgettable episodes of severe dizziness accompanied by tinnitus, a feeling of ear fullness, and hearing loss.
These episodes do not occur daily and last longer than the brief episodes seen in benign paroxysmal positional vertigo, nor do they last for days like vestibular neuritis.
Most patients experience dizziness for about 3 to 4 hours before gradually improving, but episodes may recur weeks later.
Many elderly patients report having experienced recurrent dizziness since their youth, with gradually worsening hearing and persistent tinnitus.
This condition typically occurs between the ages of 20 and 40 and has a maternal inheritance pattern.
The cause is believed to be endolymphatic hydrops in the inner ear, leading to a sensation of ear fullness.
Treatment primarily involves medical management, including neuroprotective agents, vasodilators, and mild sedatives.
If episodes occur once a month, treatment should last at least four months; if they occur every two months, treatment should last at least five months, which is the interval between episodes plus three months.
If medication is ineffective or the patient cannot tolerate long-term medication, endolymphatic decompression surgery may be considered.
2.
Sudden Sensorineural Hearing Loss
"Sudden" means that the patient can clearly identify a specific day or even a moment when they suddenly lost hearing or experienced severe ringing.
This is considered an ENT emergency, and patients are generally advised to seek immediate hospitalization.
Some patients may also experience dizziness and vomiting, necessitating differentiation from Meniere's disease.
Typically, it only causes dizziness once, lasting for a day or several days, but does not recur, although hearing loss and tinnitus persist.
Meniere's disease, on the other hand, involves recurrent dizziness, but hearing often recovers more quickly after episodes.
A small number of acoustic neuroma cases may also present with sudden hearing loss, requiring a CT scan for differential diagnosis.
The causes are widely accepted to include inner ear circulatory disorders, viral infections, and autoimmune diseases, and treatment has shifted from a "shotgun" approach to targeting the specific underlying cause for each case.
1) Inner ear circulatory disorders: This occurs when blood vessels supplying the inner ear become blocked or spasmodic, leading to hypoxia and hearing impairment.
It is more common in patients with systemic vascular diseases such as diabetes, hypertension, or hyperlipidemia.
Treatment primarily involves plasma expanders (e.g., Dextran), which is a glucose polymer with a molecular weight of 40,000 that reduces blood viscosity and prevents thrombosis.
2) Viral infections: Many viruses can infect the inner ear, such as the rubella virus and cytomegalovirus, which can cause congenital deafness in fetuses; mumps virus, measles virus, herpes zoster virus, and the recently prevalent influenza virus can cause acquired deafness.
Treatment typically involves corticosteroids, starting with a dose of 60 mg for six days, then tapering over a total treatment period of two weeks.
3) Autoimmune diseases: Patients often have systemic autoimmune diseases, such as systemic lupus erythematosus or rheumatoid arthritis, and may experience bilateral hearing loss.
Diagnosis is based on medical history, physical examination, and electronystagmography (ENG) to determine whether the condition is central or peripheral.
Hospitalization for at least one week is generally recommended; if hearing does not improve, the patient may be discharged; if there is improvement, they may stay for another week.
During hospitalization, daily hearing tests and eye movement changes are recorded, and follow-up appointments are scheduled every two weeks for three months after discharge to monitor hearing recovery.
Several indicators affect prognosis: 1) The earlier treatment begins, the better the prognosis; 2) Patients with high-frequency hearing loss have a poorer prognosis; 3) Patients with dizziness have a poorer prognosis, while those with tinnitus still have cochlear nerve function, indicating a better prognosis; 4) Older patients have a poorer prognosis.
○ Noise-Induced Tinnitus
Generally, noise-induced tinnitus can be divided into chronic noise exposure and acute trauma-induced tinnitus.
The former is often due to long-term exposure to noisy environments, while the latter can result from events such as explosions, gunfire, fireworks, or the current trend of rock concerts and portable music players.
1.
Chronic Noise-Induced Hearing Loss
Modern industrial society has brought prosperity but also created a noisy environment.
Many work environments can lead to occupational injuries, such as railways, factories, airports, auto repair shops, DJs, video game store employees, and stockbrokers.
Noise levels below 80 decibels are less likely to cause hearing damage, but exposure to noise levels above 100 decibels for more than eight hours can easily lead to temporary threshold shifts.
If individuals avoid noisy environments quickly, hearing can recover.
However, if permanent threshold shifts occur, hearing cannot be restored.
Pathologically, the outer hair cells in the inner ear may degenerate, with stereocilia fused or absent, resulting in irreversible tissue damage.
Labor safety regulations have established permissible exposure limits for continuous or intermittent noise to protect workers' hearing, which can serve as a reference for your daily life and work.
In principle, the maximum permissible industrial noise level is 90 decibels, and exposure should not exceed eight hours per day.
2.
Acute Trauma-Induced Hearing Loss
Acute trauma-induced hearing loss refers to inner ear damage caused by intense external sound stimuli over a short period.
This is a direct physical injury from mechanical waves.
Young people often frequent rock concerts, karaoke, and pubs, and may experience tinnitus, hearing loss, and a sensation of ear fullness the next day, which can be termed "disco deafness," "karaoke deafness," or "portable music player deafness." After the presidential election, several patients presented with symptoms of ear fullness, ear pain, and tinnitus after exposure to loudspeakers at campaign headquarters.
Additionally, the high-pressure shock waves from the recent explosion on Wall Street lasted more than 1.5 milliseconds, while the shock waves from gunfire typically last less than 1.5 milliseconds.
Unlike irreversible hearing loss caused by long-term exposure to noisy work environments, these situations result from short-term auditory trauma, and medication treatment is very effective.
It is strongly recommended to seek prompt treatment to restore hearing.
However, if noise levels exceed 130 decibels and exposure is prolonged (such as the continuous 250 decibels often heard during weddings and funerals), it can also lead to a decrease in the ear's adaptation to noise, resulting in irreversible damage similar to chronic noise-induced hearing loss.
○ Metabolic Tinnitus
The most common cause of metabolic tinnitus among the population is hyperlipidemia, which has surged due to the economic prosperity of modern society, leading to widespread nutritional excess.
In neurotology clinics, up to 10% of patients may suffer from this condition.
Patients with hyperlipidemia often complain of feelings of "dizziness, dullness, and tinnitus," expressing a sense of discomfort.
The mechanisms leading to tinnitus include: 1.
The blood vessels in the inner ear are very delicate and lack collateral circulation, making it easy for lipids to deposit in the cochlea.
2.
Increased blood viscosity can lead to poor circulation in the inner ear and embolism.
Patients with hyperlipidemia seen in internal medicine clinics often have other conditions such as hypertension, diabetes, vascular sclerosis, or heart disease, requiring several months of medication before seeing effects.
In contrast, patients with hyperlipidemia seen in neurotology clinics often present with tinnitus and dizziness as their initial symptoms, without accompanying internal diseases, and typically feel significantly better after just one week of medication.
Among all symptoms, dizziness responds best to treatment, followed by tinnitus, while hearing loss shows no improvement.
If patients stop medication after normalizing their lipid levels but do not pay attention to their diet, recurrence is likely.
However, once they resume medication, they quickly feel relief.
Subsequent blood tests show lipid levels returning to normal, supporting this hypothesis.
○ Vascular Tinnitus
The vertebral artery supplies blood to the brain and inner ear through the transverse foramina of the cervical vertebrae, merging with the basilar artery and branching into the anterior inferior cerebellar artery, posterior inferior cerebellar artery, and superior cerebellar artery.
If the arteries supplying the inner ear become blocked or spasmodic, it can easily lead to ischemia in the inner ear, causing abnormal discharges in the auditory nerve and presenting as tinnitus.
These patients often experience dizziness, nausea, vomiting, and hearing loss, and may also have systemic symptoms such as occipital headaches, neck and shoulder pain, and numbness in the limbs due to insufficient blood supply to the posterior cranial fossa.
Most patients are elderly and often have comorbidities such as hypertension, diabetes, heart disease, or hyperlipidemia.
For vascular tinnitus, which arises from poor blood circulation, traditional treatments often involve vasodilators to achieve therapeutic effects.
However, in cases of vascular stenosis due to atherosclerosis, vasodilators cause systemic vasodilation and do not selectively dilate only the inner ear vessels.
It is now widely accepted that treatment should focus on improving hemodynamics, increasing the deformability of red blood cells, and reducing blood viscosity to ensure the inner ear receives adequate oxygen and nutrients.
"Vasoactive agents," which are medications designed based on this concept, include those derived from natural ginkgo biloba and synthetic options.
Red blood cells have a diameter of about 7 micrometers, while the true diameter of capillaries is only 3 to 4 micrometers.
These medications can enhance the deformability of red blood cells, allowing them to pass through hardened vessels more easily; they can also act on blood vessels to reduce spasms and prevent platelet aggregation, thereby promoting smooth blood flow.
○ Tumor-Related Tinnitus
In the field of otolaryngology, unilateral tinnitus should raise suspicion for two types of tumors: nasopharyngeal carcinoma and acoustic neuroma.
This disease has also been mentioned in my article "A Talk on Dizziness," and I will post it again.
◎ Acoustic Neuroma
The auditory nerve runs from the inner ear to the brainstem, with tumors most commonly occurring at the opening of the internal auditory canal, specifically at the cerebellopontine angle (CPA).
Initially, patients may only experience gradual unilateral hearing loss or tinnitus.
This tumor grows very slowly, so even if it compresses the vestibular nerve, central compensation may prevent dizziness.
As the tumor enlarges and compresses blood vessels, it can lead to sudden hearing loss or dizziness, and symptoms can become quite varied as the disease progresses.
If an acoustic neuroma is confined to the internal auditory canal and is less than 1 cm in size, it may be difficult to detect on a CT scan.
Therefore, some practitioners perform a lumbar puncture to introduce air into the brain's ventricles, allowing the patient to lie on their side so that air enters the internal auditory canal.
If an acoustic neuroma is present, the air will not fill the internal auditory canal, which is known as "air CT." The downside is that patients may experience headaches for about a week due to the air in the cranial cavity.
With the advent of magnetic resonance imaging (MRI), tumors smaller than 1 cm can now be easily diagnosed.
If the tumor grows larger and extends towards the cerebellum or brainstem, it may pose a life-threatening risk.
Clinically, patients may present with normal hearing and no dizziness, but auditory brainstem responses may show no reaction, necessitating consideration of this condition.
● Prevention is Better than Treatment
After classifying the various causes of tinnitus, we learn that many factors leading to tinnitus can be prevented in advance.
Patients with Meniere's disease should pay attention to their diet and avoid excessive salt intake.
The increase in cases of sudden sensorineural hearing loss may be related to the development of civilization and lifestyle stress.
Occupational noise injuries are often difficult to treat, so it is crucial to monitor noise levels in the work environment.
Early treatment of acute trauma-induced hearing loss is very effective, and it is even more important to avoid places that may cause injury.
For metabolic tinnitus, in addition to controlling internal diseases, appropriate exercise and avoiding greasy foods can help maintain normal cholesterol levels.
● Self-Assessment for Tinnitus
From some carefully designed question-and-answer techniques, we can often determine the possible causes of a patient's tinnitus.
Here are some simple questions:
1.
Is the tinnitus accompanied by dizziness? Does it get louder during dizziness? Tinnitus associated with dizziness suggests the possibility of "cochlear tinnitus." Meniere's disease, sudden sensorineural hearing loss, and anterior inferior cerebellar artery obstruction are often unilateral; vertebrobasilar insufficiency tends to be bilateral.
Additionally, tinnitus in Meniere's disease tends to worsen during dizziness.
2.
Is the work environment noisy? Have you worked in a high-noise environment for a long time? Have you ever been exposed to gunfire? Have you been injured by fireworks? As mentioned above, the human ear can tolerate noise levels of up to 90 decibels, and exposure should not exceed eight hours per day.
If tinnitus occurs, it is essential to leave the noisy environment to prevent irreversible damage to the cochlear hair cells.
Standard ear protection can only block 30 to 40 decibels of noise and is ineffective against high-decibel sounds like airplane engines, trains, and lathes.
3.
Have you had blood tests for cholesterol levels? Do you have anemia, high or low blood pressure, thyroid disease, diabetes, or arteriosclerosis? Tinnitus caused by systemic vascular diseases is often bilateral, so it is essential to rule out these internal diseases in tinnitus patients.
4.
Are you taking any long-term medications? Have you received antibiotic injections? Some medications, such as aspirin, quinine, contraceptives, antihypertensives, and antipsychotics, can sometimes cause bilateral tinnitus, which resolves upon discontinuation.
Older physicians sometimes administered streptomycin, kanamycin, or gentamicin, which can also lead to tinnitus with prolonged use.
Therefore, if tinnitus occurs after an injection, it is crucial to stop the injection to prevent irreversible damage.
5.
Is the tinnitus high-pitched or low-pitched? Is it unilateral or bilateral? Auditory nerve lesions typically present with high-pitched tinnitus, while Meniere's disease or middle ear disorders often present with low-pitched tinnitus.
Cochlear tinnitus is usually unilateral, while central vascular tinnitus is often bilateral.
6.
Does the tinnitus synchronize with your heartbeat? If the tinnitus is synchronized with the heartbeat or pulse, it may indicate a vascular malformation or venous anomaly.
If the tinnitus diminishes or disappears when the neck is turned towards the affected side, it may be due to excessive pulsation in the neck vessels.
7.
Is the tinnitus related to breathing? General respiratory infections or Eustachian tube obstruction caused by flying can lead to tinnitus.
Overactive Eustachian tubes can also cause tinnitus, often accompanied by a sensation of ear vibration during breathing.
If the body bends down to tie shoelaces, the symptoms may immediately alleviate due to increased blood flow to the brain.

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Reply Date: 2004/12/06